Get Oca Official Form No 960 Authorization For Release Of - Ellenvilleregional

The OCA Official Form No 960 is a crucial document that allows individuals to authorize the release of their health information in compliance with HIPAA regulations. This guide provides clear, step-by-step instructions on how to properly fill out this form to ensure your health information is shared correctly.

Follow the steps to complete the form accurately.

1. Click the ‘Get Form’ button to access the form and open it in a suitable editor.
2. Begin by filling in your name in the 'Patient Name' field, followed by your date of birth, Social Security number, and address.
3. In the next section, affirm your request that health information regarding your care and treatment be released. Acknowledge that this authorization may disclose sensitive information by reviewing the conditions outlined in the form.
4. If applicable, initial the specific lines under Item 9(a) to authorize the release of any sensitive health information, such as mental health or HIV-related information.
5. Enter the name and address of the health provider or entity releasing your information—Ellenville Regional Hospital—ensure accuracy in your entry.
6. Next, designate the person or category of people to whom your information will be sent in Item 8.
7. Choose the specific information to be released by checking the relevant boxes in Item 9(a) and provide the date range if necessary.
8. Indicate the reason for the release of information in Item 10 by checking the appropriate box.
9. If you are not the patient, fill out the name of the person signing the form in Item 12 and provide the authority to sign on behalf of the patient in Item 13.
10. Finally, sign the form, indicate the date, and ensure you understand your rights and have received a copy of the completed form.

Complete your documentation needs efficiently by filling out the form online today.